Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
A complaint survey was conducted with no deficiencies cited.
Findings
A complaint survey was conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
An onsite complaint survey was conducted with no deficiencies cited.
Findings
An onsite complaint survey was conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
An onsite complaint survey was conducted with no deficiencies cited.
Findings
An onsite complaint survey was conducted with no deficiencies cited.
Inspection Report
Capacity: 70
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 found no deficiencies.
Findings
Recertification survey for Medicare under Life Safety Code 2012 found no deficiencies.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Nov 20, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding staffing levels and accuracy of nurse staffing postings at Alta Mesa Health and Rehabilitation.
Complaint Details
Multiple residents and a resident's spouse complained about short staffing, long wait times for care, slow response to call bells, and inadequate assistance. The facility received complaints about staffing and call light wait times, which were investigated by the administrator and staffing coordinator.
Findings
The facility failed to ensure accurate and complete Daily Staff Postings for nursing staff hours scheduled and worked, resulting in discrepancies that could affect staffing metrics. Multiple residents and family members reported concerns about short staffing and long wait times for care, particularly on weekends.
Deficiencies (1)
Failure to ensure Daily Staff Postings for nursing staff were accurate and completed for scheduled and actual hours worked.
Report Facts
RN actual worked hours discrepancy: 4.58
Average census: 68
Average census range: 55
Average census range: 63
RN hours per resident per day: 23
National average RN hours per resident per day: 28
Arizona average RN hours per resident per day: 30
Number of CNAs per shift: 4
Number of licensed nurses per building: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #39 | Certified Nursing Assistant (CNA) | Interviewed regarding staffing and workload |
| Staff #31 | Staffing Coordinator | Interviewed about staffing practices and discrepancies in staffing postings |
| Staff #83 | Administrator | Interviewed regarding staffing concerns, complaints, and facility policies |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to administer oxygen as ordered to a resident and concerns about inaccurate nurse staffing postings and staffing shortages.
Complaint Details
The complaint investigation revealed that resident #510 had not been administered oxygen since admission despite physician orders. Interviews with staff confirmed the resident was not receiving oxygen. The facility also had issues with inaccurate nurse staffing postings, with discrepancies between posted and actual hours worked, and resident complaints about short staffing and long call light wait times.
Findings
The facility failed to ensure that oxygen was administered as ordered to one sampled resident, which could result in low oxygen saturations. Additionally, the facility failed to accurately post daily nurse staffing hours, leading to discrepancies that could impact staffing metrics and resident care.
Deficiencies (2)
Failure to administer oxygen as ordered to resident #510, resulting in potential low oxygen saturations.
Failure to ensure accurate and complete daily nurse staffing postings, resulting in discrepancies between scheduled and actual hours worked.
Report Facts
Oxygen order flow rate: 2
CNA to resident ratio: 28
Registered Nurse hours worked discrepancy: 4.58
Facility census: 68
Registered Nurse hours per resident per day: 23
National average RN hours per resident per day: 28
Arizona average RN hours per resident per day: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #61 | Certified Nursing Assistant | Interviewed regarding oxygen administration process and confirmed resident was not receiving oxygen |
| Staff #113 | Licensed Practical Nurse | Interviewed about oxygen administration process and risks of non-administration |
| Staff #76 | Assistant Director of Nursing | Interviewed and verified oxygen order and charting, discussed risks of non-administration |
| Staff #39 | Certified Nursing Assistant | Interviewed about staffing and workload |
| Staff #31 | Staffing Coordinator | Interviewed about staffing discrepancies and census |
| Staff #83 | Administrator | Interviewed about staffing concerns, complaints, and CMS rating |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
State compliance survey with investigation of multiple intakes cited 2 deficiencies related to nursing documentation and respiratory care.
Findings
State compliance survey with investigation of multiple intakes cited 2 deficiencies related to nursing documentation and respiratory care.
Deficiencies (2)
R9-10-412.B — Nursing personnel documentation
R9-10-419 — Respiratory care services
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
Investigation of facility reported complaint with no deficiencies cited.
Findings
Investigation of facility reported complaint with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
Complaint survey conducted with census 57 and no deficiencies cited.
Findings
Complaint survey conducted with census 57 and no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Capacity: 70
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
Recertification survey under Life Safety Code 2012 found no deficiencies.
Findings
Recertification survey under Life Safety Code 2012 found no deficiencies.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 8
Date: Sep 15, 2023
Visit Reason
State compliance survey with investigation of multiple complaints cited 8 deficiencies related to care plans, quality of care, accident hazards, food safety, and chemical storage.
Findings
State compliance survey with investigation of multiple complaints cited 8 deficiencies related to care plans, quality of care, accident hazards, food safety, and chemical storage.
Deficiencies (8)
R9-10-403.C — Administrator policies and procedures
§483.21(b) — Comprehensive care plans
§483.25 — Quality of care
§483.25(d) — Accident hazards
§483.60(i) — Food safety requirements
R9-10-414.B — Care plan development and implementation
R9-10-423.A — Food establishment contracts
R9-10-425.A — Poisonous or toxic materials storage
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and ensure the facility meets healthcare standards.
Findings
The facility was found deficient in multiple areas including failure to implement a complete care plan for bathing for one resident, failure to provide appropriate treatment and care according to orders for another resident resulting in a critical lab value not being acted upon, unsafe chemical storage in the kitchen, and improper food storage practices.
Deficiencies (4)
Failure to develop and implement a complete care plan for bathing for resident #17.
Failure to provide appropriate treatment and care according to orders for resident #215, including failure to notify provider or pharmacy of critical vancomycin lab results.
Failure to ensure chemicals were safely stored in the kitchen, with chemicals stored on an open shelf and kitchen door left open.
Failure to properly store food, including uncovered or unsealed food items in the walk-in refrigerator and freezer.
Report Facts
Vancomycin serum trough level: 49.6
Vancomycin administration dates: 7
Discard date: 2023
Quantity of hash browns: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | MDS Coordinator | Interviewed regarding lack of bathing care plan for resident #17 |
| Staff #12 | Director of Nursing | Interviewed regarding bathing care plan and vancomycin trough monitoring |
| Staff #60 | Licensed Practical Nurse | Interviewed about vancomycin trough monitoring and notification procedures |
| Staff #102 | Assistant Director of Nursing | Interviewed about vancomycin trough monitoring and pharmacy coordination |
| Staff #11 | Dietary Supervisor | Interviewed about chemical and food storage practices |
| Staff #84 | Staff written up for failing to confirm lab values prior to medication administration | |
| Staff #188 | Administrator | Interviewed about chemical and food storage policies and supervision |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
Complaint investigation with no deficiencies cited.
Findings
Complaint investigation with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 4, 2022
Visit Reason
The inspection was conducted to investigate complaints related to the hiring practices of a Certified Nursing Assistant with a prior disciplinary action, PASARR screening deficiencies, medication administration errors, and medication error rates.
Complaint Details
The complaint investigation focused on hiring a CNA with a prior disciplinary action for abuse/neglect, failure to update PASARR screenings for residents, medication administration errors, and medication error rates.
Findings
The facility failed to ensure a Certified Nursing Assistant with a prior abuse/neglect disciplinary action was not hired, failed to update PASARR screenings for residents staying longer than 30 days, failed to administer medications according to professional standards for two residents, and had a medication error rate of 8.57% for one resident.
Deficiencies (5)
Failed to ensure a Certified Nursing Assistant was not hired with a finding of resident abuse or neglect from the State professional licensing board.
Failed to implement policies and procedures to prevent abuse, neglect, and theft related to hiring practices.
Failed to ensure PASARR screening was completed or updated for residents staying longer than 30 days.
Failed to ensure medication administration met professional standards of quality for two residents.
Failed to ensure medication error rate was not 5% or greater, with an error rate of 8.57% for one resident.
Report Facts
Hire date: Jun 20, 2022
Medication error rate: 8.57
Medication administration time: 8.13
Medication administration time: 8.38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Certified Nursing Assistant | Named in deficiency for prior disciplinary action and improper hiring |
| Staff #48 | Director of Nursing | Interviewed regarding hiring process and medication administration |
| Staff #20 | Human Resources Director | Interviewed regarding certification verification and hiring process |
| Staff #66 | Executive Director | Interviewed regarding hiring process and notification of disciplinary actions |
| Staff #54 | Activities/Social Services Supervision | Interviewed regarding PASARR screening process |
| Staff #106 | Licensed Practical Nurse | Observed and interviewed regarding medication administration of Glipizide |
| Staff #110 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors for resident #4 and #34 |
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